Va Form 10 0426 – Fill Out and Use

Department of Veterans Affairs Meds by Mail Order Form

A mail order prescription service for qualified CHAMPVA and Spina Bifida beneficiaries

This form is for Prescription Orders Only

Important Information

●This form must be filled out completely including your Social Security number and Date of Birth for identification purposes. If you cannot be identified, your prescription will not be filled.

●Attach the original prescription to this form. Photocopies of prescriptions are not accepted.

●This order form is required EVERY TIME a written prescription from your medical provider is mailed.

●This form is to be completed by the patient, family member, or caregiver with power of attorney.

●Use a separate form for each patient or family member.

●Medication delivery may take up to 21 days from the date you mail your order. To ensure that you have enough medication to last until your shipment arrives, request a second written prescription for a 30-day supply from your medical provider that can be filled at your local pharmacy.

●This mail order service is provided only for maintenance medication―that is, medications that are required for extended periods of time. All immediate-use or one-time-use prescriptions and all CII controlled substance prescriptions must be obtained at your local pharmacy.

Patient Prescription Information

This form must be filled out completely - TYPE or PRINT information below:

Mailing Information (Type or Print where the prescriptions are to be mailed)

Address 1			Home:			Cell:

Address 2

Today's Date:

City

NON-SAFETY CAP REQUEST:

Federal law requires that your medication be dispensed in a

State

Zip

container with a child resistant or safety cap. If you would like your

prescription with an “Easy-Open” lid, please sign below:

I request that these prescriptions and all refills of these

Is this a change of address?

Yes

No

prescriptions dispensed in “Easy-Open” or NON-child-resistant

Is this a permanent change?

Yes

No

containers.

Is this a temporary change?

Yes

No

Signature:

Medication Allergies

Health Conditions

No known allergies

Arthritis

Glaucoma

Liver Disease

Aspirin

NSAIDS

Asthma

Heart Problem

Seizures/Epilepsy

Cephalosporin

Penicillin

COPD

High Cholesterol

T Thyroid

Codeine

Sulfa

Depression

Hypertension

Ulcer/Acid Reflux

Erythromycin

Tetracycline

Diabetes

Kidney Disease

Other (specify)

Other (specify)

Food Allergy (specify)

VA

FORM

10-0426

Page 1 of 2

JAN

2016

VA FORM

10-0426

Page 1 of 2

DEC 2016

Where to Mail your Prescriptions:

WEST		EAST
If you live in one of the following states or		If you live in one of the following districts, states or
territories, mail your order form to the address		territories, mail your order form to the address
listed below:		listed below:
Alaska, American Samoa, Arizona, Arkansas,		Alabama, Connecticut, Delaware, Florida,
California, Colorado, Guam, Hawaii, Idaho, Illinois,		Georgia, Kentucky, Maine, Maryland,
Indiana, Iowa, Kansas, Louisiana, Michigan,		Massachusetts, Mississippi, New Hampshire,
Minnesota, Missouri, Montana, Nebraska, Nevada,		New Jersey, New York, North Carolina, Ohio,
New Mexico, North Dakota, Northern Mariana		Pennsylvania, Puerto Rico, Rhode Island, South
Islands, Oklahoma, Oregon, South Dakota, Texas,		Carolina, Tennessee, Vermont, Virginia, Virgin
Utah, Washington, Wisconsin, Wyoming.		Islands, Washington D.C., West Virginia.
Telephone:	1-888-385-0235	Telephone:	1-866-229-7389
Address:	Meds by Mail	Address:	Meds by Mail
	PO Box 20330		PO Box 9000
	Cheyenne, WY 82003-7008		Dublin, GA 31040-9000

How to Request Prescription REFILLS:

This form is for use when you send a paper prescription written by your medical provider. Refill orders should be placed by calling our automated refill system. Simply call 1-888-370-1699 and follow the voice prompts. Refill orders may also be placed using the refill slip that accompanies each shipment of medication. If you choose to reorder by mail, be sure to return your refill slip as soon as you receive your prescription order, as it may take up to 21 days to process your order. DO NOT DELAY in requesting your refills. Read the refill slip carefully, it contains information you will need concerning the number of refills remaining and the prescription expiration date.

E-prescribing Information

We now accept electronic prescriptions directly from your doctor. Ask your doctor if they can e-prescribe and tell them the name of the pharmacy is listed as: “Meds by Mail CHAMPVA”

Provider Information

Provider Name:

Provider Contact:

VA FORM	10-0426	Page 2 of 2
DEC 2016